Method For Providing A Disease Management Service

ABSTRACT

The present invention generally relates to the field of medical services and more specifically to the area of chronic disease management. It comprises a new method for providing a disease management service which utilizes nurse practitioners to engage in regularly scheduled virtual evaluation and management “office visits” with patients, using off-the-shelf videophones for real-time video and audio communications. As these disease management services are delivered to the patient while he remains in his home, such convenient access to professional health care brings about a much closer monitoring of the patient&#39;s condition than would be otherwise practical, enabling clinicians to make necessary therapeutic modifications in a timely fashion. Engaging patients in such regularly scheduled office visits also causes increased compliance with recommended regimens and lifestyle modifications, resulting in overall improved management of the patient&#39;s chronic condition. Patients are enrolled into the service primarily through referrals from their primary care physicians who sign a Collaboration Agreement with the chronic disease management service. The Collaboration Agreement extends the continuity of care for enrolled patients by keeping the primary care physician informed at all times on the health status of their patients and involved in all important clinical decisions regarding patients referred to the service. The secure Internet-accessible clinical documentation and information systems used in the disclosed method make possible a multi-office practice were information can be seamlessly shared and patient workloads can be distributed across multiple locations. Clinical office visit services provided under the disclosed method qualify for reimbursement by public insurers and many private insurers. The disclosed method represents a novel form of medical practice whose area of operation and potential patient base is unbounded by geographic location, since patients may engage in virtual office visits while remaining in their homes, and the information technology infrastructure utilized allows the disclosed disease management service to deliver medical care from any location that has phone service and an Internet or network connection available.

BACKGROUND OF INVENTION

1. Field of the Invention

The disclosed invention relates generally to the field medical practice,and more specifically to the areas of chronic disease management andtelemedicine. The term telemedicine refers to the delivery of medicalservices or information to a site other than that where the healthprofessional providing such medical services or information is located.Inasmuch as many diseases cannot be cured, they are considered chronicand the patient must undergo various forms of therapy for the durationof his life. Various techniques that have been developed in the medicalfield that are designed to improve the clinical outcomes for patientssuffering from chronic diseases are collectively referred to as chronicdisease management, or simply as disease management. The methoddisclosed herein relates to a new kind of medical service that appliestelemedicine technology to chronic disease management in a novel way,which overcomes many of the obstacles which have previously hindered theuse of telemedicine technology in everyday patient care, and whichimproves upon existing disease management practices by providingpatients a more convenient and effective way to regularly accessqualified medical practitioners to help them manage their chroniccondition. The disclosed disease management service is designed tointegrate and coordinate the continuum of care for patients enrolled inthe service.

2. Background of the Invention and Prior Art

The method disclosed herein describes a comprehensive technique fordelivering direct patient care that joins together in a novel way, twoareas of medical practice; telemedicine and chronic disease management.The disclosed method represents a financially viable business methodthat also produces superior clinical results as compared to traditionaldisease management practices.

The historical roadblocks and problems that have hindered theproliferation of telemedicine as a viable treatment tool are wellunderstood. They are:

General lack of third-party reimbursement—Cross-state licensingdifficulties for providers

Cost of telemedicine-enabling technology—The difficulty of usingcomplicated telemedicine-enabling technology for both healthprofessionals and patients

Concerns about malpractice liability associated with telemedicine

Traditional physician patient-referral patterns and their desire toretain patients under their care

Concerns regarding confidentiality of patient information

Because of these issues, telemedicine implementations to date rarelyinvolve direct patient care delivered by a individual health provider.Implementations have been for the most part limited to: home monitoringof physiological parameters, military use (where many of the samefactors do not apply), demonstration projects, specialty medical imagingtelemedicine systems for radiology, and medical specialty consultationsbetween physicians. In short, telemedicine technology to date has beenused almost exclusively as a physician-to-physician consultation tool ora clinical information-gathering tool, rather than aphysician-to-patient treatment tool.

The method and system disclosed herein addresses all of above-mentionedproblems, resulting in a financially viable disease management servicebusiness method that integrates direct patient care with telemedicinetechnology and which dovetails with the efforts of other healthcareentities involved in the care or insured coverage of the patient.

The disclosed method is specifically designed to treat patients whosuffer from chronic diseases. Due to the chronic nature of theirdisease, frequent visits to the office of a medical professional by thepatient is typically required to keep the physician abreast of theprogress of the disease, so that he may make appropriate treatmentrecommendations and modifications. These office visits often pose agreat difficulty and burden to the patient, who may be significantlydebilitated by his disease, and who may even require the use of anambulance to transport the patient to the appointment. Also, the natureof the modern medical practice makes it difficult to schedule suchchronic patients at the frequency they may require to maintain optimumhealth. Lower reimbursement rates for evaluation and management officevisits, particularly from public insurers, cannot sustain the physicaloverhead and salary requirements of a modern medical practice whoseschedule is too heavily loaded with such clinically complex patients. Asa consequence of the these factors, patients suffering from chronicdisease may not see their primary care physician as frequently asmedical guidelines recommend, often resulting in dramatic decline inoverall health to the patient, and higher costs to the health system.

The method herein described creates a solution to this problem byallowing the patient to remain in their home during regularly scheduledevaluation and management office visits that are conducted by aqualified nurse practitioner in the employ of the disclosed diseasemanagement service. The reduced overhead resulting from using nursepractitioners rather than physicians to conduct evaluation andmanagement office visits, coupled with the elimination of the officespace and personnel normally required to physically accommodate patientsin a typical medical office, render the described method a financiallyviable means of providing more frequently scheduled disease managementservices to patients.

The relationship between a primary care physician and his patient is acarefully guarded one. Physicians are hesitant to refer patients toother clinical providers, if they feel there is a chance they may losecontrol of the care of their patient. This legitimate concern isaddressed in the design of the disclosed method by means of theCollaboration Agreement enacted between the primary care physician andthe disclosed disease management service. Under the terms of thisagreement, the primary care physician retains control over the care ofthe patient. The disease management service's nurse practitioners serveas dependable clinical partners to the primary care physician, reportingregularly on the patient's health status and collaborating in his care.Collaborating primary care physicians always have access to currentinformation relating to their patient's condition, and are involved inimportant decisions relating to the care and treatment of the patient.This creates a consistent continuum of care for the benefit of thepatient, and results in a lower overall financial cost to the healthsystem.

While medical practice licenses for physicians are granted on astate-by-state basis, medical practice licenses for nurses and nursepractitioners have intrastate licensing programs in place that make itmuch simpler to achieve professional licensing in multiple states fornurse practitioners than it is for physicians. In many states, nursepractitioners enjoy similar prescriptive powers as primary carephysicians. For most insurers, Evaluation and Management medicalservices delivered by nurse practitioners are billed at the same rate asfor primary care physicians, even though salaries for nursepractitioners are generally much less than those for physicians.Liability insurance for nurse practitioners is considerably lessexpensive than liability insurance for practicing physicians. Thecombination of these factors make nurse practitioners the ideal healthcare professional to deliver telemedical chronic disease managementservices over a wide geographical area, and additionally provide a basisfor a feasible business model for establishing a disease managementservice such as that herein disclosed.

Potential problems regarding confidentiality of patient information is aprimary consideration in the design of the disclosed method. All patientinformation that is recorded by the nurse practitioners is transmittedusing secure encrypted electronic formats, and is securely stored in acentral database. The information infrastructure described herein iscompliant with the most recent comprehensive governmental regulationsconcerning confidentiality of patient data. Patients enrolled in thedescribed disease management service must sign a release form before anypatient data is shared with other parties and healthcare system.

The invention does not claim any novel technology advancements withrelation to the hardware and software that are employed in the describedmethods and systems used to deliver this service. However, theirapplication in the context of the disclosed method is novel. All of thevideophone hardware, computer hardware and computer software used inimplementing the disclosed service are based on international standardsand are available off-the-shelf, with the exception of the softwaredeveloped for documenting the patient encounters and analyzing resultantdata. This clinical documentation and analysis software is highlyspecialized and is developed by the disease management service. Thereadily available videophones used in the service are relativelyinexpensive and are as easy to use as a regular telephone; no specialskills are required to operate the telemedicine technology. Also, thevideophones used require no special phone lines in order to operate.Since there are no restrictions or required specifications regardingvideoconferencing hardware employed in the delivery of generaltelemedicine services, any equipment that meets the subjective standardsof the patient and the practitioner can potentially be utilized by thedisclosed disease management service, including PC-basedvideoconferencing.

Several patents have been issued which refer to a centrally locatedvideoconference devise, or to a cart that carries various components ofa central videoconferencing station to be used for telemedicine-basedencounters. In the invention described herein, distinguishes itself fromthose patents in that there is no central videoconferencing station atthe nurse's location, but rather each nurse practitioner has one (orseveral) small videophone appliances on his or her desk. Encounters withpatients are person-to-person, point-to-point. When a multipointconference with another caretaker is desired, an off-the-shelfmultipoint control unit may also be utilized to establish and conductsuch a conference.

In contrast to interventional videoconferencing telemedicine systemsthat are designed to be used on an ad hoc basis, the described method isnot an “emergency” service by nature, but rather is characterized byconsistently scheduled office visits between the Nurse Practitioner andthe patient. The overall duration of the patient's participation in thedisease management service may be from several months to many years. Itis well understood that patients who attend regular evaluation andmanagement office visits with a medical practitioner generally realizesignificantly improved outcomes. For reasons cited herein, such regularoffice visits are difficult to achieve in the real world. The disclosedmethod mitigates those factors that inhibit regularly scheduledevaluation and management visits with a qualified health practitioner.

A number of patents have been issued for disease managementtechnology-based systems that collect certain health data elements viavarious methods and devices, and which then store or analyze the data(or both), and the results are delivered as raw data or formattedreports to various parties involved in the healthcare system. Thisinvention distinguishes itself from these types of previously issuedpatents, in that what is being claimed is a direct patient care deliverymethod in which services rendered are billable under standard medicalinsurance office visit claim codes. As described in the disclosedmethod, the extensive utilization of secure Internet-accessible centraldata repositories for creating, analyzing and distributing data servesto make its operation more efficient, enhances its ability to coordinatepatient care with other healthcare entities, and also serves to removethe limitation of geographic location since records can be created andaccessed from anywhere, services can be delivered from anywhere, andpatients can be treated without leaving their own homes.

Traditionally, medical practices that provide direct patient careoperate within a set geographical region. This is due to both interstatelicensing requirements as discussed above and also to the fact that hemedical offices must be convenient for the patient to travel to. Anotherreason is that the patient's medical records must be available forreview when a patient is seen. The vast majority of medical practicesstill rely on paper-based medical records that are stored and filed intheir place of business, close to their examination rooms. While somelarge multi-state practices do exist, they invariably have separatephysical offices located in their various practice locations, so thatpatients can be seen in person at the office where his records arestored. The disclosed disease management service describes a novel formof medical practice that can deliver chronic disease patient care fromany location, irrespective of the location of the patient.

In order to be successful, current state-of-the-art disease managementpractices ultimately depend on the patient's willingness and ability toattend scheduled appointments with his primary care physician or otherspecialized healthcare provider. Healthcare demographic statistics showthat a large percentage of those suffering from chronic diseases fail toattend such appointments for a variety of reasons. As a result, thissegment of the patient population represents a disproportionately largeexpense to the healthcare system, as these conditions can quicklydegenerate into more costly and life-threatening complications if notmonitored consistently, and appropriate treatments ordered in a timelyfashion. The disclosed method mitigates and overcomes many of thefactors that prevent or dissuade patients from attending regular officevisits with qualified medical practitioners, since they can regularlyattend office visits without leaving their homes, and thereforerepresents a fundamental improvement over existing practices.

DETAILED DESCRIPTION

Organizational Structure of the Disease Management Service

The entity which controls or owns the disclosed disease managementservice may be formed as a corporation, a partnership or any other legalform of organization, as the form of ownership is not relevant to theclaims being made herein. Employees of the disease managementorganization fall generally into four categories: executive, sales,administrative and clinical. As the claims being made in thisapplication relate primarily to the manner of operation and method ofproviding disease management services, discussion of the operativefunctions of executives and sales employees is not relevant to theclaims, and so will not be discussed here.

Nurse practitioners deliver the clinical “evaluation and managementoffice visit” services that are the primary product of the discloseddisease management service. A licensed physician supervises every nursepractitioner in the employ of the disease management service. Thesesupervising physicians are not necessarily employees of the discloseddisease management service, nor are they necessarily primary carephysicians who refer patients to the service. The primary focus in theoperation of the service is to maximize the percentage of time nursepractitioners spend on direct patient care, and to minimize the amountof time they must spend on tasks that may be classified asadministrative in nature, such as clinical documentation in schedulingfor office visits conducted with enrolled patients.

Administrative employees perform a variety of functions to support thedelivery of the disease management services. Administrative supportfunctions include; enrollment of patients, scheduling of patients,reminder calls to patients, gathering of various clinical data elementsfrom patients in preparation for their encounter with the nursepractitioner, fielding questions from patients about the servicesoffered, working with patients to resolve technical problems with theirvideophones, billing for services performed by nurse practitioners,maintenance of information systems, responding to technical andadministrative questions from physicians, working with insurancecompanies, and other miscellaneous tasks.

Location and Configuration of Offices

Since virtually all of the clinical care and administrative functions ofthe disease management service in the preferred embodiment arecomputer-based or network-based, there are no restrictions on locationof either administrative or clinical offices. The entire diseasemanagement service may operate out of a single large office, or it couldjust as easily and effectively operate out of many widely dispersedoffices. The primary requirements for physical plant location andconfiguration are that high-speed communication lines are available toany disease management service location, and that offices must havesufficient physical security to meet Federal regulations regarding thesafety and privacy of clinical patient information. Within any clinicaloffices of the disclosed service, there must be sufficient semi-privateareas with appropriate lighting within the offices for the nurses toconduct their patient visits with a minimum of interference. Since manyembodiments of the disclosed method are possible as regards physicalconfiguration and location of offices, there could potentially beseparate offices containing executive, administrative, informationtechnology and technical support personnel, but without clinicalfunctions performed in that location.

While the disclosed disease management service could optionally usepaper records rather than computerized records in implementing theservice, doing so would create additional administrative overhead inmanaging the records and extracting data from them for the purposesdescribed herein. Using paper records would also require additionaladministrative personnel at each clinical location to manage therecords, which would not be required in computerized records were used.The use of paper records would not limit the geographical area orpatient base that could be served by the disclosed service, but it wouldmake it less efficient in its operation and would also require thatnurse practitioners have on-site administrative support personnelavailable to them to manage paper medical charts. Thus, using paperrecords is within the scope of these claims, however it is not thepreferred embodiment since doing so would increase the complexity andcost of providing the service, rendering it less profitable and lessconvenient for those interacting with the service such as primary carephysicians, pharmacists and insurers.

Nurse practitioners who deliver the disease management services, areprovided with the appropriate type of videophone hardware required tocommunicate with their patients, and are also provided with a local areanetwork or Internet-connected computer terminal. Since in its preferredembodiment, the disease management service enables nurse practitionersto operate autonomously without any on-site physical supportrequirements other than their videophone and computer terminal, they maywork out of a variety of settings including an office in their home, orout of an office of the disease management service. When working out ofan office of the disease management service, nurse practitionerworkstations are typically located in a semi-private cubicle type ofenvironment, in order to minimize environmental background noise andvisual distractions during their virtual office visits with theirpatients.

Videophone Technology

Videophones used in providing the service are installed at both thenurse practitioner's workstation, and also in the patient's home orother location convenient for the patient. Videophones may be of severaltypes, depending on which telephone network services are available atthe patient's location. Thus, videophones employed by the service mayoperate in analog mode for those without digital services, IP-basedvideophone appliances may be installed where such network services areavailable to the patient, or PC-based videophones could also be used.The claims made herein do not depend upon any particular type ofvideophone being utilized in the delivery of the disease managementservices. Any communication device that can deliver real-time video andaudio between the two parties with sufficient subjective image qualitycan be used.

Patient Enrollment

The primary method for enrolling patients into the disclosed diseasemanagement service is through referrals from collaborating primary carephysicians. A formal Collaboration Agreement is established between thedisease management service and primary care physician. ThisCollaboration Agreement defines the terms and methods of referringpatients into the disease management service, as well as otherresponsibilities of both parties. Primary care physicians are recruitedinto this collaborative relationship by a variety of means. The servicemay employ inside or outside salesman to contact individual physicians,physician groups, physician networks, insurers or other professionalgroups or organization's in which physicians participate. In thisfashion, individual physicians, as well as groups of physicians arerecruited and, if they choose to do so, will sign the CollaborationAgreement with the disclosed disease management service. Directmarketing methods targeting primary care physicians such as e-mail, fax,advertisements and targeted mailings may also be used in the recruitingeffort.

Patients may also be enrolled into the disease management servicethrough contracts with other types of health care entities. Healthnetworks, health insurers and similar entities may engage the diseasemanagement service to provide care to a subset of their chronic diseasepopulation. Primary care physicians of patients referred to the servicein this manner are contacted by the disease management service regardingtheir participation in the care of their patient, and are offered theopportunity to sign the Collaboration Agreement with the diseasemanagement service. If they choose to do so, the structure and termswill be in place for the referral of other patients under the care ofthe primary care physician.

Individual patients may also elect to enroll in the disease managementservice of their own volition. Individual patients may be recruited byseveral means including but not limited to: mass mailings, Internetmarketing, e-mail campaigns and television advertisements. Whenindividual patients are successfully enrolled into the diseasemanagement service, their primary care physicians are contacted by asalesperson. The benefits of the service are then presented to thephysician, and he is asked at that time to sign the CollaborationAgreement with the disease management service.

Collaboration Agreement

The Collaboration Agreement defines the working relationship between thedisclosed disease management service and primary care physicians orother healthcare providing entities that refer patients to the diseasemanagement service. The collaboration agreement features the followingprovisions:

The Collaboration Agreement defines the methods and processes to be usedfor referral of patients to the disease management service by theprimary care physician are defined.

The Collaboration Agreement stipulates that the referring physicianretains primary control over the health care of any patient he refers tothe disease management service.

The Collaboration Agreement stipulates that the primary care physicianwill be notified and/or consulted if there are any significant changesin patient's health status, or if changes to the patient medicationregimens may be necessary.

In the Collaboration Agreement, the disease management service agrees toprovide the primary care physician access to clinical documentationgenerated by the disease management service for patients he has referredto the service.

In the Collaboration Agreement, the primary care physician agrees toperiodically review clinical documentation generated by the diseasemanagement service for his referred patients.

In the Collaboration Agreement, the disease management service agrees toreimburse the physician for time spent in reviewing the above clinicaldocumentation and for time spent collaborating with the diseasemanagement service's nurse practitioners.

Videophone Shipping and Patient Setup

Referred patients from all sources are each telephoned by administrativepersonnel. In the call, patients are notified that they have beenreferred to the disease management service by their primary carephysician or other health-care provider, and are asked if they areinterested in enrolling.

If referred patients decline to enroll, then his referring physician orother referral source is so notified.

If the patient accepts enrollment, then the administrative personinitiating the call collects the patient's personal and medicalinformation, and arrangements are made for a videophone to be shipped tothe newly enrolled patient. Videophone hardware is provided to enrolledpatients free of charge.

After the videophone arrives, the patient may install the videophonehimself if he feels he is capable, or he may request help from thetechnical support personnel at the disease management service. Once thevideophone is installed and tested, an administrative person calls thepatient to set up an initial virtual office visit with his assignednurse practitioner.

The patient's participation in the disclosed disease management servicemay be terminated by his own decision, or by a mutual decision betweenthe patient and his primary care physician. When a patient leaves thedisease management program, the videophone hardware is returned to thedisease management service.

Scheduling and Clinical Support

In order to maximize the time spent on direct patient care,administrative staff members manage patient schedules for nursepractitioners. Each patient has a nurse practitioner assigned to him atthe time he is enrolled. If the primary assigned nurse practitioner isnot available for some reason, the administrative staff will temporarilydesignate another nurse practitioner to care for the patient in hisstead. As a reminder for upcoming visits, administrative staff attemptsto contact patients ahead of the scheduled appointment. When patientsfirst enroll into the program, they are scheduled for once a weekappointments at a specified time and day of the week. As the patientprogresses through the disease management program, their scheduledoffice visits may become less frequent than every week. If the patientreaches a sufficient level of control over their chronic condition, hisweekly appointments may scale back to once every two weeks, thenpossibly to once a month. Patients, or their physicians on their behalf,may elect to exit the disease management service at any time.

Administrative personnel of the disease management service handle allscheduling of nurse practitioner/patient virtual office visits, andplace reminder calls to patients for upcoming visits. Specializedsoftware to manage the scheduling function is run on a server that islocated in the administrative offices of the disease management service,or may be co-located at another secure location. Nurse practitionersaccess their schedules using the computer terminal provided by thedisease management service. Connections to the scheduling server fromthese computer terminals may be via a secure local area networkconnection, or via a secure connection over the Internet. In thescheduling software, nurse practitioners have the ability to adjusttheir own schedules in the event that a patient may not be available toattend a regularly scheduled office visit.

Videophone Technical Support

Any technical problems that patients may be having with theirvideophones are reported to the administrative staff by the nursepractitioner. The administrative staff then calls the patient on thephone and attempts to resolve any reported videophone hardware problems.If the problems cannot be resolved, then new videophone hardware is sentto the patient before the next appointment, and the faulty videophonehardware is picked up and returned to the disease management service.

Delivery of Patient Care

When the time for the scheduled appointment with the patient hasarrived, the nurse practitioner will call the patient on theirvideophone. After the patient answers, the video connection isestablished and the parties can see and hear each other. During thevirtual office visit, the nurse will follow standardized protocols inher interaction with the patient. Specific clinical protocols to be usedwill vary with the diagnosis of the patient. At the conclusion of theoffice visit, each party will hang up the videophone; the nursepractitioner will finish their clinical documentation for the encounter,and will then call the next scheduled patient and repeat the process.

Standardized Clinical Protocols

Standardized clinical protocols are developed by the clinical staff ofthe disease management service, and conform to the standards of care forthe disease state, or states, that the patient is suffering from. Beforeseeing patients on behalf of the disease management service, employeenurse practitioners are trained in this specialized telemedicine-basedmethod of healthcare delivery, as well as in the standardizeddisease-state clinical protocols. The structure and content of theseprotocols is reflected and embodied in the formal clinical documentationthat each nurse practitioner generates at the conclusion of each virtualoffice visit. Depending on the disease state(s) of the patient being“seen”, appropriate documentation forms are presented to the nursepractitioner on her computer terminal Clinical Documentation In thepreferred embodiment, clinical documentation for patient “office visits”is created via a secure connection to a central server that holds theprimary clinical databases for the disease management service. All nursepractitioners are provided with computer terminals that allow them toaccess these clinical databases. An intuitive user interface is providedto the nurse practitioners that enable them to easily review historicalmedical records of their patients, as well as to create new clinicaldocumentation for their virtual office visits. Common chronic diseaseshave associated parameters which can be objectively measured, and whichare useful to clinicians in gauging the progress of the disease and thehealth of the patient. Depending upon which disease state is beingtreated, measurements for relevant parameters are recorded by the nursepractitioners into the clinical databases during their office visit withtheir patients. Off-the-shelf electronic medical devices may also beutilized to record and transmit data representing various physicalparameter measurements, with said data being transmitted to the officesof the disease management service and input into the patient recordeither by automatic electronic means or by transcription into thedatabase of the transmitted measurements. All of the data andobservations generated from nurse practitioner office visits or frommedical devices, can be output from the central database as formattedelectronic or paper documents which conform to industry-standardclinical documentation for the type of office visit service beingprovided. Paper or electronic versions of the clinical documentation canthen be appropriately communicated to physicians, insurers and otherhealthcare entities involved in the care of the patient. In thepreferred embodiment, physicians are given user names and passwords andaccess patient documentation via a secure connection to the centraldatabase of the disclosed disease management service.

Pharmacist Review and Conference

A primary objective in the design of the disclosed disease managementservice is to integrate the services it provides with the continuum ofcare of the patient. In the medical field, the clinician mostknowledgeable regarding potential contraindications or appropriatenessof the prescription drug regimen for any given patient, is thepharmacist. Patients often see several physicians in the course of theirtreatment, and they may not correctly report all of their prescriptionsto physicians who may be treating them, or medications they have beenprescribed. Consequently, unbeknownst to their primary care physician,many patients may be taking a combination of pharmaceuticals that areless than ideal, or that may even be harmful to them. In its preferredembodiment, the disclosed disease management service includes apharmacist review designed to minimize dilatory effects ofcontraindicated drug regimens, and to maximize the health benefit of anyprescribed regimen for the patient given their diagnosis and currenthealth condition. Once the assigned nurse practitioner has becomefamiliar with the patient's history and has an accurate list of hiscurrent drug regimen, a three-way conference between the nursepractitioner, the patient, and a pharmacist may take place. With thepermission of the patient, his current drug regimen and relevant medicalhistory is shared with the pharmacist by paper-based or electronicmeans. As an alternative to a three-way conference, the nursepractitioner may introduce and then refer the patient to the pharmacist,after which the patient and the pharmacist may engage in a one-on-onediscussion regarding the patient's condition and medication regimens.Pharmacists who perform this service regularly for enrolled patients ofthe disease management service will be provided with their ownvideophones so that they can conduct virtual face-to-face meetings withpatients. If the primary care physician for any given patient has signeda collaboration agreement with the disease management service, he willbe consulted before any medication changes that may have beenrecommended by the pharmacist are put into effect.

Working with Primary Care Physicians

Since primary care physicians who have signed Collaboration Agreementsare the main source for referrals of patients to the disclosed diseasemanagement service, the relationship with them is carefully constructedand managed to keep them constantly updated on the health status oftheir enrolled patients. A feature of the design of the discloseddisease management service is that the collaborating primary carephysician must approve all decisions regarding significant changes inthe care and therapies of his patients. This gives the collaboratingphysician a measure of assurance that he will not lose control of hispatient's care. Furthermore, the combination of the physician'sknowledge and skill with that of the nurse practitioner works for thebenefit of the patient.

Collaborating physicians also receive, or have access to, regulardetailed clinical reports on the status of their patients, includingvisit notes from the encounters between the patient and the nursepractitioner, graphical representations of various health parameters,any medication change requests have been made as well as other reportsthat may vary according to the particular patient's diagnosis.Collaborating physicians who do not have Internet access will receivethese reports in paper format or in electronic media such as CD-ROM.Collaborating physicians who do have Internet access are givenpassword-protected secure access to the central database at the diseasemanagement service, with read-only permissions to view medical recordsfor their enrolled patients. For physicians receiving documentation inthis fashion, there is no requirement to physically mail them paper orelectronic media-based reports.

A key feature of the disclosed disease management service is thatcollaborating physicians are reimbursed by the disease managementservice for the time they spend reviewing these records and reports. Inthe preferred embodiment, Physicians are reimbursed at a fixed rate,which is based on the number of virtual office visit records they revieweach month. At the end of each period (usually a month) thecollaborating physician signs a document stating how many of the nursepractitioner office visit records he reviewed on behalf of his enrolledpatients during that month. Upon receiving this document, the diseasemanagement service will reimburse the collaborating physician accordingto the fixed-rate schedule that is included in his CollaborationAgreement. While fixed-rate reimbursement of physicians is used in thepreferred embodiment, other methods of reimbursement may also be usedwithin the scope of the claims herein presented.

Billing Insurers for Services

In its preferred embodiment, administrative personnel working for thedisease management service perform the task of billing for medicalservices provided by nurse practitioners. However, the manner and methodof billing is not integral to the claims made herein. Documentationgenerated by nurse practitioners during each virtual office visit isused to determine proper industry standard medical service billing codesto be submitted to insurers for reimbursements. Reimbursements receivedfrom insurers for claims submitted are assigned to the diseasemanagement service by all employee nurse practitioners. The billingcodes used are the same codes that are used for traditional in-personoffice visits, with the exception that a special add-on telemedicinemodifier code may be appended to the normal billing code, where suchtelemedicine modifier codes are provided by insurers.

1. A disease management service method whereby the medical servicesdelivered to patients enrolled in the service consists of evaluation andmanagement “office visits” that are conducted by nurse practitioners,with said office visits being conducted using videophones to enablereal-time audio and video communications between the nurse practitionerand the patient, where the patient is situated in his home or otherconvenient location, and the nurse practitioner is situated at a worklocation remote from that of the patient.
 2. The method of claim 1,whereby the nurse practitioners who provide these evaluation andmanagement office visit medical services on behalf of the diseasemanagement service are employees of the disease management service. 3.The method of claim 1, whereby the nurse practitioners who provide theseevaluation and management office visit medical services on behalf of thedisease management service are supervised by a licensed physician. 4.The method of claim 1, whereby the services rendered to patientsenrolled in the disease management service consist of evaluation andmanagement office visits, conducted by nurse practitioners with bothpatient and practitioner using videophones to enable these officevisits.
 5. The method of claim 1, whereby patients enrolled in thedisease management service are provided with videophones by the diseasemanagement service, with said videophones being installed at thepatient's home or other location convenient to the patient. Saidvideophones are provided free of charge to the patient so that he mayparticipate in virtual evaluation and management office visits withremotely located nurse practitioners.
 6. The method of claim 1, wherebysaid videophones are returned to the disease management service by thepatient at the termination of their participation in the diseasemanagement program.
 7. The method of claim 1, whereby the diseasemanagement service submits claims for reimbursement for clinical officevisit services to both public and private insurers on behalf of itsemployee nurse practitioners who have provided said office visitservices to enrolled patients. These claims for reimbursement aresubmitted to insurers using the same standard medical industry servicecoding used for traditional “in person” office visits. In those caseswhere the insurer also provides for a special add-on telemedicinemodifier code, such code is added to the standard medical industryservice codes.
 8. The method of claim 1, whereby the employee nursepractitioners assign their insurer claim reimbursements for servicesrendered on behalf of the disease management service, to the diseasemanagement service.
 9. A disease management service method, whereby thedisease management service establishes a formal patient referral andcollaborative relationship with primary care physicians or otherhealth-care entity, by means of a Collaboration Agreement.
 10. Themethod of claim 2, whereby the Collaboration Agreement may also beentered by a group of primary care physicians or a healthcare entityother than an individual primary care physician.
 11. The method of claim2, whereby under the terms of the Collaboration Agreement, the methodsand conditions of referral of patients to the disease management serviceby the primary care physician are defined.
 12. The method of claim 2,whereby under the terms of the Collaboration Agreement, patients areenrolled into the disease management service through a referral fromtheir primary care physician.
 13. The method of claim 2, whereby theCollaboration Agreement stipulates that the referring physician retainsprimary control over the healthcare of any patient he or she refers tothe disease management service.
 14. The method of claim 2, whereby theCollaboration Agreement stipulates that the primary care physician of anenrolled patient will be notified and/or consulted if there are anysignificant changes in patient's health status, or if changes to thepatient medication regimens may be necessary.
 15. The method of claim 2,whereby under the terms of the Collaboration Agreement, the diseasemanagement service provides the primary care physician access toclinical documentation generated by the disease management servicerelevant to those patients who have been referred to the diseasemanagement service.
 16. The method of claim 2, whereby under the termsof the Collaboration Agreement, the primary care physician agrees toperiodically review clinical documentation generated by the diseasemanagement service regarding his referred patients.
 17. The method ofclaim 2, whereby under the terms of the Collaboration Agreement, thedisease management service agrees to reimburse the primary carephysician for time spent in reviewing the above clinical documentationfor his enrolled patients, and for time spent consulting with thedisease management service's nurse practitioners on his patients' cases.The rates of said reimbursements are defined within the terms andconditions of the aforementioned Collaboration Agreement.
 18. The methodof claim 2, whereby utilizing various direct marketing techniques,prospective patients may be recruited directly by the disclosed diseasemanagement service. Primary care physicians of successfully recruitedpatients are then contacted and are asked to sign the CollaborativeAgreement.
 19. A disease management service method whereby the followingfunctions are conducted over a secure Internet connection, or a localarea network connection, to a central database: creation of all newclinical documentation, access to existing clinical documentation by thenurse practitioners and referring primary care physicians, clinical dataanalysis, patient scheduling functions, management of videophonetechnical support requests and shipping, billing functions andadministrative functions. Internet-connected servers at the primaryadministrative offices of the disease management service, or othersecure location, manage all of the above functions and hold all theclinical and administrative data related to the operation of the diseasemanagement service. This feature of the disclosed disease managementservice enables both the clinical and administrative functions tooperate efficiently from multiple geographic locations, and provides acentral repository from which data related to the operation of theservice can be analyzed and shared with other entities involved inproviding health-related services to the patient as described herein.20. The method of claim 3, whereby each nurse practitioner employed bythe disease management service, regardless of their physical location,is provided with a computer terminal. Each of these computer terminalshas a secure connection to the central servers of the disease managementservice, either through a local area network or by secure connectionsthrough the Internet. These computer terminals provide nursepractitioners access to all clinical documentation for their patients,which reside in a database on the central servers of the diseasemanagement service. Likewise, all new clinical documentation relating topatient encounters is created and updated on the same central databasethrough use of the computer terminals by the nurse practitioners. 21.The method of claim 3, whereby primary care physicians for patientsenrolled in the disease management service are given secure Internetaccess to the electronic medical records of their own patients, thuskeeping the primary care physicians abreast of the patient's healthstatus and allowing the physicians to effectively collaborate with thedisease management nurse practitioners in the care of the patient. 22.The method of claim 3, whereby when permission is given by a patient, alicensed pharmacist may be given secure Internet access to electronicmedical records for selected patients, in order to review their medicalhistory and current medication regimen. In this way, pharmacists canmake appropriate recommendations regarding medications and effectivelycollaborate with the disease management nurse practitioners in the careof the patient.